Guidelines for Medical Necessity



6540515684500Guidelines for Medical NecessityDetermination for Mastectomy for Gynecomastia This edition of Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information MassHealth requires to determine medical necessity for mastectomy for gynecomastia. These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs.Providers should consult MassHealth regulations at 130 CMR 415.000 (acute inpatient hospital services), 433.000 (physician services), 410.000 (outpatient hospital services), and 450.000 (administrative and billing regulations), and Subchapter 6 of the Physician Manual for information about coverage, limitations, service conditions, and other prior-authorization (PA) requirements applicable to this service.Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), integrated care organization (ICO), senior careorganization (SCO), or program of all-inclusive care for the elderly (PACE) should refer to the ACPP’s, MCO’s, ICO’s, SCO’s, or PACE’s medical policies for covered services.1MassHealth reviews requests for PA for mastectomy for gynecomastia on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions.Section I. General InformationGynecomastia is an enlargement in the glandular tissue of the breast in males. It can occur physiologically (normally) in newborns, adolescents, and older men. Increase in fatty tissue due to obesity in the male breast is not gynecomastia. It is called pseudogynecomastia. Occasionallygynecomastia will be associated with pain or tenderness. Gynecomastia may occur in both breasts or only on one side. In newborns, gynecomastia usually resolves without any interventions within four weeks. In adolescent boys, gynecomastia occurs around puberty but goes away within six months to two years. Approximately 20 percent of gynecomastia in adolescents can continue into adulthood. In men over the age of 50, decreasing free-testosterone levels can lead to gynecomastia.Pathologic (caused by diseases) causes of gynecomastia include certain health conditions such as chronic liver disease, chronic kidney disease, low hormone levels (which occur in hypogonadism), hyperthyroidism, testicular tumors, or malnutrition. In addition, certain medications and treatments can also lead to gynecomastia. These include cancer treatments like chemotherapy, prostate cancer therapies and testicular irradiation, hormone treatments, anabolic steroids, and medications for diseases such as heartburn, anxiety, depression, human immunodeficiency virus, and fungal infections. Substance use including alcohol, amphetamines, marijuana, and heroin or methadone may cause gynecomastia, as can the use of herbal substances like lavender, tea tree oil, and dong quai. In thesepage 1guidelines for medical necessity determination for mastectomy for gynecomastiaMNG-MAST-GYN (10/18)cases, the treatment of the underlying disease and/or discontinuing the use of medications and substances contributing to the gynecomastia often results in regression of the breast tissue.Male breast cancer is rare (less than 0.2 percent in excised breast specimens with a diagnosis of gynecomastia), but it is important to rule out by a thorough history, a physical, and diagnostic testing if indicated by exam. In approximately 25 percent of cases, nonphysiologic gynecomastia is idiopathic, meaning that there are no identifiable causes found after a complete history, a physical, and complete diagnostic testing have been performed.2MassHealth considers approval for coverage of mastectomy for gynecomastia on an individual, case- by-case basis, in accordance with 130 CMR 450.204.Section II. Clinical GuidelinesClinical CoverageMassHealth bases its determination of medical necessity for mastectomy for gynecomastia on a combination of clinical data and the presence of indicators that would affect the relative risks and benefits of the procedure, including postoperative recovery. The procedure is medically necessary when all the following criteria are met.AdolescentsCompletion of puberty, and adult testicular size has been achieved (tanner stage 5); ANDThe presence of Grade II or higher gynecomastia on physical examination per adapted gynecomastia scale from McKinney and Simon, Hoffman and Kohn Scales; ANDEnlargement of the breast due to glandular tissue, as confirmed by physical examination, mammogram, or biopsy; ANDPhysiologic or idiopathic gynecomastia persisting for two years after onset, or pathologic gynecomastia persisting for one year after reversible causes are completely corrected or removed; ANDThe presence of symptoms including, but not limited to, breast pain or tenderness; ANDNo evidence of the use of medication or substances that can contribute to gynecomastia, such as marijuana, supplements, herbal products, or steroids within the last year.AdultsThe presence of Grade III or higher gynecomastia on physical examination per adapted gynecomastia scale from McKinney and Simon, Hoffman and Kohn Scales (Appendix A); ANDEnlargement of the breast due to glandular tissue, as confirmed by physical examination, or mammogram, or biopsy; ANDPhysiologic or idiopathic gynecomastia persisting for two years after onset, or pathologic gynecomastia persisting for one year after reversible causes are completely corrected; ANDThe presence of symptoms including, but not limited to, breast pain or tenderness; ANDNo evidence of the use of medication(s) or substance(s) that can contribute to gynecomastia, such as marijuana, supplements, herbal products, or steroids within the last year.NoncoverageMassHealth does not consider mastectomy to be medically necessary under certain conditions. Examples of such conditions include, but are not limited, to the following.For the treatment of pseudogynecomastia, including enlargement of the breast due to excess adipose tissue; or3For purposes of improving the appearance of the body, when the medical necessity guidelines are not met.Section III: Submitting Clinical DocumentationDocumentation supporting medical necessity must include all of the following.A current (within the last six months) comprehensive medical history includingall concurrent diagnoses;date of onset of gynecomastia and associated symptoms;current and past medications used (for one year), whether prescribed or over the counter;current and past herbal and recreational drugs used (for one year); andsurgical history;A current comprehensive physical exam, includingheight;weight;breast exam;testicular exam; andtanner stage of development (for adolescents);Current (within the last six months) diagnostic testing includingserum testosterone levels’estradiol levels;luteinizing hormone levels;beta human chorionic gonadotropin levels;thyroid-stimulating hormone levels; anda comprehensive metabolic panel;Photo documentation of gynecomastia (front and lateral, shoulder to waist, taken within the last six months);A surgical treatment plan; andAdditional pertinent clinical information that MassHealth may request.Clinical information must be submitted by the treating surgeon. Providers are strongly encouraged to submit requests electronically. Providers must submit all information pertinent to the diagnosis using the Provider Online Service Center (POSC) or by completing a MassHealth Prior Authorization Request form (using the PA-1 paper form found at masshealth) and attaching pertinent documentation. The PA-1 form and documentation should be mailed to the address on the back of the form. Questions regarding POSC access should be directed to the MassHealth Customer Service Center at (800) 841-2900.ReferencesAmerican Society Plastic Surgeons (2002). ASPS Recommended Insurance Coverage Criteria for Third Party Payers. Approved March, 2002 and reaffirmed by the Executive Committee, June 2015. Retrieved on April 12, 2018 from Positions/Gynecomastia_ICC.pdfBraunstein GD. Clinical practice. Gynecomastia. N Engl J Med. 2007;357(12):1229–1237Carlson HE. Approach to the patient with gynecomastia. J Clin Endocrinol Metab. 2011;96:15-21.Dickson G. Gynecomastia. Am Fam Physician. 2012 Apr 1;85(7):716-722. Accessed January 2016 from P, Carrero JJ, Díez JJ. Gonadal dysfunction in men with chronic kidney disease: clinical features, prognostic implications and therapeutic options. J Nephrol. 2012;25(1):31–42Lapid, O, Jolink, F, Meijer, SL. Pathological findings in gynecomastia: Analysis of 5113 breasts. Annals of Plastic Surgery. 2015; 74(2):163-166Sotos JF, Tokar NJ. Appraisal of testicular volumes: volumes matching ultrasound values referenced to stages of genital development. International Journal of Pediatric Endocrinology. 2017;2017:7. doi:10.1186/s13633-017-0046-x.Swerdloff RS, Ng JCM. Gynecomastia: Etiology, Diagnosis, and Treatment. [Updated 2015 Aug 3]. In: De Groot LJ, Chrousos G, Dungan K, et al., editors. Endotext [Internet]. SouthDartmouth (MA): , Inc.; 2000-. Available from: NBK279105/.These Guidelines are based on review of the medical literature and current practice in mastectomy for gynecomastia. MassHealth reserves the right to review and update the contents of these Guidelines and cited references as new clinical evidence and medical technology emerge.4618008866360This document was prepared for medical professionals to assist them in submitting documentation supporting the medical necessity of the proposed treatment, products, or services. Some language used in this communication may be unfamiliar to other readers; in this case, contact your health care provider for guidance or explanation.Revised Policy Effective: October 24, 2018Approved by: Jill Morrow-Gorton MD, MBAActing Chief Medical Officer, MassHealthSupersedes policy dated: October 1, 2005 Appendix AGynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scalesGrade ISmall breast enlargement with localized button of tissue that is concentrated around the areolaGrade IIModerate breast enlargement exceeding areola boundaries with edges that are indistinct from the chestGrade IIIModerate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy presentGrade IVMarked breast enlargement with skin redundancy and feminization of the breast ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download